SOUTH BAY PATHOLOGY SOCIETY CASE SUBMISSION FORM
SOUTH BAY PATHOLOGY SOCIETY CASE SUBMISSION FORM
Please complete this submission form and submit one or two blocks and corresponding slides to the registrar. Special stains, including immunohistochemical stains are welcome, but not required (please indicate whether you want these returned). Please include the pathology report, consultation reports and pertinent x-rays, laboratory data and reference articles. Kodachromes of the gross lesion should be included if available. Bone lesions are not accepted without copies of the x-rays.
CONTRIBUTOR:______________________________________________________________
CONTRIBUTOR'S
E-MAIL ADDRESS:_____________________________________________
CONTRIBUTING
FACILITY:____________________________________________________
CASE
ACCESSION NUMBER:____________________________________________________
TISSUE
OR ORGAN:__________________________________________________________
HISTOLOGIC
DIAGNOSIS:_____________________________________________________
CLINICAL
SUMMARY:_________________________________________________________
__________________________________________________________________________
GROSS
PATHOLOGICAL DESCRIPTION:___________________________________________
__________________________________________________________________________
RESULTS
OF SPECIAL STAINS, OTHER TESTS, ETC.:_____________________________
__________________________________________________________________________
CONSULTANT
OPINIONS:______________________________________________________
__________________________________________________________________________
PERTINENT
REFERENCES:_____________________________________________________
__________________________________________________________________________
ARE
THERE AVAILABLE ( ) KODACHROMES OF GROSS LESION? (
) PHOTOMICROGRAPHS?
If so, please submit or
inform the Registrar BEFORE the meeting scheduled for
presentation of the number of Kodachromes
you plan to present.
Joshua Sickel
MD. Registrar,